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2. Important Instructions

   Please be as comprehensive, detailed and specific as possible in your responses to questions included on the form. An acknowledgement of your request will be provided to you by email within approximately two weeks after the date of submission. We respectfully request that you do not use Mayor Clarke's name on any public relations material (notifications, invitations or agendas) until you have received written approval from the Waukee City Clerk.

4. Event Overview
6. Event Name*
8. Event Date*
   Event Date
9. Flexible Date*

   If your requested event date is flexible, please enter your preferred date above and select "Yes" so we may suggest alternative dates if available.

   1. Yes
   2. No
13. Event Logistics
15. Event Start Time*
    Event Start Time

    Event Start Time
16. Event End Time*
    Event End Time

    Event End Time
18. Event Information*
20. Event Address*
21. Apt./Suite/Other
23. City*
24. State*
25. Zip Code*
27. Number of Attendees*
28. Who's in the Audience?*
32. Organization and Contact Details
34. Organization/Business*
36. First Name*
37. Last Name*
39. Phone Number*
40. Email Address*
42. About Your Organization*
46. Event Details
48. Tentative Run of Show/Agenda of Events*
50. Summary/Background of Event*
52. Mayor's Proposed Speaking Role*
    -- Select One --2-3 Minutes of Remarks5 Minutes of Remarks10 Minutes of Remarks15+ Minutes of RemarksPanelAttending Without Remarks
53. Is the Mayor receiving an award?*

    1. Yes
    2. No
55. If yes, please describe:
57. Theme of Event (if any) to help prepare talking points:
58. Key Points about event for remarks:*
60. Additional Information
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field